State Pension (Non-Contributory)

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1 Application form for State Pension (n-contributory) Social Welfare Services SPNC 1 Data Classification R You need a Personal Public Service Number (PPS.) before you apply. How to complete this application form. Please tear off this page and use as a guide to filling in this form. Please answer all questions. Incomplete forms will be returned and this may delay your application. Please use black ball point pen. Please use BLOCK LETTERS and place an X in the relevant boxes. If you do not have a spouse, civil partner or cohabitant: Please fill in Parts 1 to 6. When form is completed, read Part 10 and sign declaration in Part 1. If you have a spouse, civil partner or cohabitant: Please fill in Parts 1 to 8. Part 9 must be filled in and signed by your spouse, civil partner or cohabitant. When form is completed, read Part 10 and sign declaration in Part 1. If you need any help to complete this form, please contact your local Citizens Information Centre, your local Intreo Centre or your local Social Welfare Office. For more information, log on to You should apply 3 months before reaching pension age. Important If you fail to provide relevant information or if you provide information which is untrue or misleading you will be required to repay any payment you received from the Department and you may be prosecuted. You must notify the Department of any change in your circumstances.

2 How to fill this form To help us in processing your application: Print letters and numbers clearly. Use one box for each character (letter or number). Please see example below. 1. Your PPS.: 2. Title: (insert an X or specify) 3. Surname: 4. First name(s): 5. Your first name(s) as appear(s) on your birth certificate: 6. Birth surname: 7. Your date of birth: 8. Your mother s birth surname: 9. Your address: T Mr. Mrs. X Ms. Other M U R P H Y M A U R E E N M A R Y M C D E R M O T T K E L L Y Contact Details 1 N E W S T R E E T O L D T O W N D O N E G A L T O W N County D O N E G A L Postcode 10.Your telephone number: 11.Your address: O N E N U M B E R P E R B O X M O B I L E O N E N U M B E R P E R B O X L A N D L I N E O N E C H A R A C T E R P E R B O X SAMPLE

3 Application form for State Pension (n-contributory) 5D00BD68 Social Welfare Services SPNC 1 Data Classification R Part 1 1. Your PPS.: 2. Title: (insert an X or specify) 3. Surname: Your own details Mr. Mrs. Ms. Other 4. First name(s): 5. Your first name(s) as appear(s) on your birth certificate: 6. Birth surname: 7. Your date of birth: 8. Your mother s birth surname: 9. Your address: Contact Details County Postcode 10.Your telephone number: M O B I L E L A N D L I N E 11.Your address: Signature (not block letters) Declaration I declare that the information given by me on this form is truthful and complete. I understand that if any of the information I provide is untrue or misleading or if I fail to disclose any relevant information, that I will be required to repay any payment I receive from the Department and that I may be prosecuted. I undertake to immediately advise the Department of any change in my circumstances which may affect my continued entitlement. If you cannot sign your name, make a mark, such as an X and have it witnessed. Signature of witness (not block letters) 6D3010CE Date: Date: Warning: If you make a false statement or withhold information, you may be prosecuted leading to a fine, a prison term or both. Page 1

4 CFF11EFF Part 1 continued 12.Are you? Your own details Single Married Separated Divorced Widowed Cohabiting In a Civil Partnership A surviving Civil Partner A former Civil Partner (you were in a Civil Partnership that has since been dissolved) 13.If you are married, in a civil partnership or cohabiting, from what date? Part 2 Your work and claim details State Pension (n-contributory) is a means tested payment. You are legally obliged to declare all your means which include money in cash or in a financial institution, savings, shares, bonds, funds, property (other than your own home), foreign pensions etc. Please include written evidence such as statements and payslips with your application. You must also declare the means of your spouse, civil partner or cohabitant even if you are not claiming an increase for a qualified adult. 14.Are you employed at present? If, please state: Employer s name: Employer s address: Gross weekly earnings: Please attach 3 of your most recent payslips. 15.Are you getting a social security payment from another country? Page 2 If, please state: Name of country: Your claim or reference number: Amount: Please attach the most recent payslip or letter from the Social Security Agency confirming the above amount and also provide a 3 month bank statement for the account to which this payment is made. 00B6C749

5 C480FEA0 Part 2 continued Your work and claim details 16.Are you getting any other pension or allowance? If, please state: Who pays this pension: Your claim or reference number: Amount: 17.Are you self-employed at present? If, please state: Type of work you do: Date you started self-employment: Net yearly earnings: Please attach the most recent payslip or letter from the people who pay you confirming the above amount and also provide a 3 month bank statement for the account to which this payment is made. a year This is the money you have made from self-employment after deducting operating expenses. 18.Do you own, share in the ownership, work or rent a farm or land? If, please state: Size of farm or land: acres Net yearly income or rent from farm or land: Net yearly income is money you have made from the farm after deducting operating expenses. 19.Do you own stocks, shares (including shares in a creamery or Co-op), annuities, bonds, funds, insurance policies or investments? If, please state: Their value: Please attach a statement to show details and current market value. AAC70402 Page 3

6 11BFB1E8 Part 2 continued Your work and claim details 20.Do you have savings or accounts in a bank, post office, building society, credit union or any other financial institution in the Republic of Ireland or another country? If, please state: Name of financial institution: Bank Identifier Code (BIC): International Bank Account Number (IBAN): Current balance: Is this account a joint account? Name(s) of account holder(s): Name 1: Name 2 (if any): Financial Institution 1 Name of financial institution: Financial Institution 2 Bank Identifier Code (BIC): International Bank Account Number (IBAN): Current balance: Is this account a joint account? Name(s) of account holder(s): Name 1: Name 2 (if any): Please attach an original statement for each account, showing transactions for the last 3 months. If you have any other accounts you must give details of them to this Department on a separate sheet of paper. Page 4 6AE2A7D2

7 Part 2 continued Your work and claim details 21.Do you have property apart from your home? If, please state: Type of property: Address of property: Property would be an apartment, business property, another house or land other than that mentioned at question 18. Current market value: Rent from this property: 23.Are you paying maintenance? If, please state: Amount: 24.Are you receiving maintenance? If, please state: Amount:,,. Please provide a valuation from a registered auctioneer or valuer. 22.Are you paying a mortgage or a housing loan for this property? If, please state: Amount of mortgage or loan outstanding: Please attach documentary evidence. Please provide a copy of the maintenance agreement.,,. 25.Do you have any other income? If, please give details in the space provided: Please provide a copy of the maintenance agreement. 4D2B517A Page 5

8 220F01F8 Part 2 continued Your work and claim details 26. Did you ever sell or transfer any property or business? If, please give details in the space provided and attach a copy of the deed of transfer: 27.Have you moved from your home? If, please outline the circumstances in the space provided. If your home is rented, occupied by other people or otherwise being used, please give details: 28.Did you recently sell your home to buy another? If, please outline the circumstances in the space provided and attach supporting documents regarding the financial transaction from your solicitor and a copy of the Deed of Transfer: Part 3 ALL questions must BE ANSWERED 29.Are you legally entitled to reside in the Republic of Ireland? 30.Were you born outside the Republic of Ireland? If, please state: Country you were born in: Your nationality: You must provide your original Birth Certificate with your application. Photocopies are not acceptable. If, when did you come to live in the Republic of Ireland? If you are a holder of a GNIB (Garda National Immigration Bureau) card, please provide a copy of this card and your letter from the Department of Justice and Equality. 31.Have you lived outside the Republic of Ireland for any period longer than three months within the last five years? Page 6 E78DDED0 Habitual Residence condition

9 60BB725E Part 4 Your payment details You can get your payment at a post office of your choice or direct to your current, deposit or savings account in a financial institution. An account must be in your name or jointly held by you. Please complete one option below. Name of financial institution: Bank Identifier Code (BIC): International Bank Account Number (IBAN): Name(s) of account holder(s): Name 1: Name 2 (if any): Financial Institution You will find the following details printed on statements from your financial institution. Post office name and address: Post Office Please enter below the name and address of the post office where you wish to collect your payment. If you are unable to collect or cash your payment at the post office and you want someone else (known as an agent) to do so for you, please complete the form AGENT authority to appoint an agent available on 0DD1C970 Page 7

10 32B8ACED Part 5 Details of your qualified child(ren) 32.Do you wish to apply for qualified child(ren)? under age 18 If, how many children do you wish to claim for? Please state child s: Surname: First name(s): PPS.: Child 1 age in full-time education Date of birth: Surname: Child 2 First name(s): PPS.: Date of birth: Surname: Child 3 First name(s): PPS.: Date of birth: Surname: Child 4 First name(s): PPS.: Date of birth: You must attach written confirmation from the school or college for the children aged te: A separate sheet of paper can be used for details of other children you have. Page 8 1B7F67F4

11 9F7404C9 Part 6 Other payments Living Alone Increase You may get a Living Alone Increase if you are getting a State Pension (n-contributory) and live alone or mainly alone. For more information, log on to 33.Do you wish to claim a Living Alone Increase? If, please state date you started living alone or mainly alone: Household Benefits Package You may qualify for the Household Benefits Package, which is made up of 2 allowances: Electricity or Gas Allowance Free Television Licence For more information, log on to Fuel Allowance This allowance is subject to your household composition. Only one person in a household can get this allowance. 34.Do you wish to apply for a Fuel Allowance? If, please go to Part 7. If, please complete fully the remainder of this section. Do not leave any question blank. If no income, please enter 0 in each box. 35.The following people live with me: Person 1 Surname: First name(s): PPS.: Relationship to you: Are they: Employed Self-employed If so, state weekly amount: Are they: In receipt of a social welfare payment Other If in receipt of a social welfare payment or other, please give details in the space provided: Weekly amount: 451B7AF0 Page 9

12 5E594B33 Part 6 continued Surname: Other payments Person 2 First name(s): PPS.: Relationship to you: Are they: Employed Self-employed If so, state weekly amount: Are they: In receipt of a social welfare payment Other If in receipt of a social welfare payment or other, please give details in the space provided: Weekly amount: Surname: First name(s): PPS.: Relationship to you: Person 3 Are they: Employed Self-employed If so, state weekly amount: Are they: In receipt of a social welfare payment Other If in receipt of a social welfare payment or other, please give details in the space provided: Weekly amount: Page

13 8C7E76E1 Part 6 continued Surname: Other payments Person 4 First name(s): PPS.: Relationship to you: Are they: Employed Self-employed If so, state weekly amount: Are they: In receipt of a social welfare payment Other If in receipt of a social welfare payment or other, please give details in the space provided: Weekly amount: Part 7 te: A separate sheet of paper can be used for details of other persons living with you. Extra benefits For more information on extra benefits available to pensioners, log on to 36.Their PPS.: Your spouse s, civil partner s or cohabitant s details 37.Title: (insert an X or specify) 38.Their surname: 39. Their first name(s) as appear(s) on their birth certificate: 40.Their birth surname: 41.Their date of birth: 42.Their mother s birth surname: 43.Their address: Only answer this question if you are married or in a civil partnership and do not live together. Mr. Mrs. Ms. Other 177D3992 Page 11

14 A9DBBD03 Part 8 Your spouse s, civil partner s or cohabitant s work and claim details If your spouse, civil partner or cohabitant is aged 66 or over they also should apply for State Pension (n-contributory) in their own right. Please complete this section for your spouse, civil partner or cohabitant, even if they are aged 66 or over. 44.Are they employed at present? If, please state: Their employer s name: Their employer s address: Their gross weekly earnings: Please attach 3 of their most recent payslips. 45.Are they getting a social security payment from another country? If, please state: Name of country: Their claim or reference number: Amount: 46.Are they getting any other pension or allowance? Please attach the most recent payslip or letter from the Social Security Agency confirming the above amount and also provide a 3 month bank statement for the account to which this payment is made. If, please state: Who pays this pension: Their claim or reference number: Amount: Please attach the most recent payslip or letter from the people who pay them confirming the above amount and also provide a 3 month bank statement for the account to which this payment is made. Page 12 76D7F2FB

15 B5CF261F Part 8 continued 47.Are they self-employed at present? If, please state: Type of work they do: Date they started self-employment: Your spouse s, civil partner s or cohabitant s work and claim details Their net yearly a year earnings: This is the money they have made from self-employment after deducting operating expenses. 48.Do they own, share in the ownership, work or rent a farm or land? If, please state: Size of farm or land: acres Net yearly income or rent from farm or land: Net yearly income is money they have made from the farm after deducting operating expenses. 49.Do they own stocks, shares (including shares in a creamery or Co-op), annuities, bonds, insurance policies or investments? If, please state: Their value: Please attach a statement to show details and current market value. 50.Do they have savings or accounts in a bank, post office, building society, credit union or any other financial institution in the Republic of Ireland or another country? If, please state: Name of financial institution: Bank Identifier Code (BIC): International Bank Account Number (IBAN): Current balance: Is this account a joint account? Name(s) of account holder(s): Name 1: Name 2 (if any): Financial Institution 1 AFC23A5E Page 13

16 64DBEEEA Part 8 continued Name of financial institution: Your spouse s, civil partner s or cohabitant s work and claim details Financial Institution 2 Bank Identifier Code (BIC): International Bank Account Number (IBAN): Current balance: Is this account a joint account? Name(s) of account holder(s): Name 1: Name 2 (if any): Please attach an original statement for each account, showing transactions for the last 3 months. If you have any other accounts you must give details of them to this Department on a separate sheet of paper. 51.Do they have property apart from their home? If, please state: Type of property: Address of property: Property would be an apartment, business property, another house or land other than that mentioned at question 48. Current market value: 53.Are they paying maintenance? If, please state: Amount:,,. Rent from this property: Please provide a valuation from a registered auctioneer or valuer. 52.Are they paying a mortgage or a housing loan for this property? If, please state: Amount of mortgage or loan outstanding: Page C9BDC,,. Please attach documentary evidence. Please provide a copy of the maintenance agreement.

17 98DE1A83 Part 8 continued 54.Are they receiving maintenance? If, please state: Amount: Your spouse s, civil partner s or cohabitant s work and claim details 55.Do they have any other income? If, please give details in the space provided: Please provide a copy of the maintenance agreement. 56. Did they ever sell or transfer any property or business? If, please give details in the space provided and attach a copy of the deed of transfer: 57.Have they moved from their home? If, please outline the circumstances in the space provided. If their home is rented, occupied by other people or otherwise being used, please give details: 58.Did they recently sell their home to buy another? If, please outline the circumstances in the space provided and attach supporting documents regarding the financial transaction from their solicitor and a copy of the Deed of Transfer: FA Page 15

18 6DEF82C4 Part 9 Spouse s, civil partner s or cohabitant s payment details Any qualified adult increase which you (the pensioner) qualify for will be paid direct to your spouse, civil partner or cohabitant unless they state otherwise. You should show them this page to let them decide if they want to receive this increase for themselves or if they want you to get paid this increase with your pension. Declaration of qualified Adult tice to Pensioner: The Remainder of this page should be filled out by the person named in Part 7. (a) I, paid directly to me., wish to have any Increase for a Qualified Adult to be OR (b) I,, wish to have any Increase for a Qualified Adult paid to my spouse, civil partner or cohabitant with their pension. If part (b) above has been signed you should let us know whether you wish to receive payment into the post office or into your account in a financial institution. Fill in one of the payment options below. Payment details You can get your payment at a post office of your choice or direct to your current, deposit or savings account in a financial institution. An account must be in your name or jointly held by you. Please complete one option below. Name of financial institution: Bank Identifier Code (BIC): International Bank Account Number (IBAN): Name(s) of account holder(s): Name 1: Name 2 (if any): Financial Institution You will find the following details printed on statements from your financial institution. Post Office Please enter below the name and address of the post office where you wish to collect your payment. Post office name and address: Page 16 CDA0CC8C

19 1F03E0C1 Part 10 checklist Please ensure that you enclose all documents requested as failure to do so may lead to your application form being returned and this may delay your application. Have you enclosed the following? You and your spouse s, civil partner s or cohabitant s most recent payslips (if you or your spouse, civil partner or cohabitant were employed during the last 12 months) Statements from all financial institutions showing the last 3 months transactions (internet printouts are not accepted) and the name and address of the account holder(s). (if you or your spouse, civil partner or cohabitant have money or investments in a financial institution) Advice slips from any pensions you or your spouse, civil partner or cohabitant are receiving. Letter from school or college. (if you are claiming for child(ren) aged between 18 and 22 who are in full-time education) If you are the holder of a Garda National Immigration Bureau card (GNIB), have you attached a copy of this card and your letter from the Department of Justice and Equality? If you are claiming for Fuel Allowance, please make sure that you have you fully completed Question 34 and 35. If you were born, married or entered into a civil partnership or a civil union outside the Republic of Ireland: Your birth certificate Your marriage certificate or civil partnership or civil union registration certificate Your spouse s, civil partner s or cohabitant s birth certificate (if applying for an increase for them) Your child(ren) s birth certificate(s) (if applying for an increase for them) te: birth certificate is needed if you are already getting Child Benefit. Original certificates only. Please remember to sign the Declaration in Part 1. If you have any difficulty in filling in this form, please contact your local Citizens Information Centre, your local Intreo Centre or your local Social Welfare Office. 6163D918 Page 17

20 826568ED Send this completed application form to: State Pension (n-contributory) Section Social Welfare Services Department of Social Protection College Road Sligo Telephone: (071) LoCall: If you are calling from outside the Republic of Ireland please call te The rates charged for using 1890 (LoCall) numbers may vary among different service providers. Data Protection Statement The Department of Social Protection will treat all information and personal data you give us as confidential. However, it should be noted that information may be exchanged with other Government Departments / Agencies in accordance with the law. Explanations and terms used in this form are intended as a guide only and are not a legal interpretation. 180K Edition: July 2015 Page 18 DF2F13B3

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